Free HCP QUICK FACTS - New Mexico

The Workers' Compensation Handbook For New Mexico

New Mexico Workers' Compensation Quick Facts for Health Care Providers
In any emergency ........................................................................................................ 1 For providers who do not take workers' comp................................................................. 1

Booklet B8:

Health Care Provider Selection ................................................................................1 Basic concerns for the health care provider..............................................................2

Detailed information is available..............................................................................4 Billing and payment................................................................................................5

Other than emergencies ­ before you treat .................................................................... 2 If the patient's employer is uninsured ............................................................................ 2 For personal assistance ­ for you or your patient ............................................................ 2 For providers located in another state ............................................................................ 3 Reasonable and necessary care ..................................................................................... 3 Return to work............................................................................................................. 3 Communicating with the employer................................................................................. 4

Pharmacy benefits..................................................................................................6 Dental care............................................................................................................6
Help from the Workers' Compensation Administration...................................................... 7 Workers' Compensation Handbook List of Booklets.......................................................... 8

Amount of payment...................................................................................................... 5 Balance billing is prohibited ........................................................................................... 5 Billing and payment disputes......................................................................................... 6

Published by the New Mexico Workers' Compensation Administration, a state agency. Laws can change. Check for new information by calling 1-866-WORKOMP or 1-866-967-5667 or look on the Internet at www.workerscomp.state.nm.us

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The Workers' Compensation Handbook for New Mexico Booklet B8: Quick Facts for Health Care Providers ______________________________________

2008 Edition page 1

This booklet is a brief overview of "basics" of the New Mexico workers' compensation system, for the physician and the administrative staff of the physician's office. It is written and provided by the New Mexico Workers' Compensation Administration (WCA), the state regulatory agency for workers' compensation system. The WCA also publishes a comprehensive guide for health care providers, called the Health Care Provider's Guide to New Mexico Workers' Compensation.

In any emergency
Treat first and catch up on paperwork later!
Emergency treatment will be covered for any legitimate work-related accident. The rule regarding emergency treatment is in the Rules of the WCA, NMAC 11.4.4.11 (C(1)). 1

Health Care Provider Selection
Your patient should know, or should be able to find out, whether he was instructed to come to you by the employer or whether the patient himself made the selection. This may become important during the course of future treatment. Advise the patient to find out.

For providers who do not take workers' comp
If you have been contacted by the patient BUT you do not intend to treat this patient for this injury:
The patient may have selected you under the health care provider selection provision of the workers' compensation law. If you refer the patient to another medical practice, you may be "using up" this patient's selection right. The patient should have a chance to decide what to do. The patient may: · contact an ombudsman at the Workers' Compensation Administration; call 1-866-WORKOMP or 1-866-967-5667; or the nearest WCA office. read the health care provider selection information in the WCA's Workbook for Injured Workers, if you have a copy of it;

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11

In this booklet are references to the Rules of the Workers' Compensation Administration. These references are in a standard form based on the numbering system of the New Mexico Administrative Code (NMAC); for example, Section 11.4.4.11 NMAC. This stands for Title 11, Labor and Workers' Compensation; Chapter 4, Workers' Compensation; and then the number of the section and exact paragraph.

Published by the New Mexico Workers' Compensation Administration, a state agency. Laws can change. Check for new information by calling 1-866-WORKOMP or 1-866-967-5667 or look on the Internet at www.workerscomp.state.nm.us

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The Workers' Compensation Handbook for New Mexico Booklet B8: Quick Facts for Health Care Providers ______________________________________

2008 Edition page 2

·

read Booklet B-4 in the WCA booklet series The Workers' Compensation Handbook for New Mexico, explaining health care provider selection. This booklet is available both in print and online at www.workerscomp.state.nm.us under "Booklets." The online version may be downloaded.

Basic concerns for the health care provider
Other than emergencies ­ before you treat
Your patient should be able to tell you: · that he or she was injured at work; · the name and address of the employer and contact information, such as the name and phone number of the human resource officer. · The patient should be able to report to you that he or she has reported the claim to the employer or to a manager or supervisor. In a legitimate work-related injury, your services should be covered. However, it is advised that you contact the payer in advance. Obtain the necessary contact information from the patient or from the contact person at the workplace.

If the patient's employer is uninsured
Advise the patient to contact the ombudsman program at the WCA -- 1-866WORKOMP or 1-866-967-5667. The patient might be eligible for coverage under a WCA program called the Uninsured Employers' Fund.

For personal assistance ­ for you or your patient
Call the WCA state headquarters or your nearest WCA field office at any of the phone numbers listed on the back page of this booklet. See the chart titled "Help from the Workers' Compensation Administration" in this booklet for more details. · For general information, guidance to publications and information about seminars, contact the Business and Public Outreach office. For assistance with claims-related issues, call the WCA ombudsman service at the special Hotline number, 1-866-WORKOMP (1-866-9675667). Several of the ombudsmen are Spanish-speaking.

·

The WCA ombudsman program is available to anyone who needs help with workers' compensation claims matters. The ombudsmen are not advocates but are neutral advisors who can help anyone with information about the process and the rights and responsibilities of the parties.

Published by the New Mexico Workers' Compensation Administration, a state agency. Laws can change. Check for new information by calling 1-866-WORKOMP or 1-866-967-5667 or look on the Internet at www.workerscomp.state.nm.us

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The Workers' Compensation Handbook for New Mexico Booklet B8: Quick Facts for Health Care Providers ______________________________________

2008 Edition page 3

The ombudsmen can be reached at 1-866-WORKOMP (1-866-967-5667) or at any of the WCA office telephone numbers on the back page of this booklet. · For assistance with technical questions related to medical treatment, billing or payment, call the Medical Cost Containment Bureau at the state headquarters.

For providers located in another state
If you are located outside New Mexico, you can be an authorized provider for a New Mexico workers' compensation patient if: · this is an emergency, OR · you apply to the WCA for approval, OR · the insurer or self-insurance program acknowledges your status on this case by paying a bill; OR · you are licensed in New Mexico as well as the other state. If the insurer or self-insurance program makes any payment for this claim, you are assumed to be approved, and the application process is not necessary. The application materials are available on the WCA web site or through the Office of the General Counsel. Application is made on a case-by-case basis. There is no process for blanket approval of an out-of-state provider. See the Rules of the WCA, NMAC 11.4.7.9(I).

Reasonable and necessary care
A workers' compensation insurance claim covers "reasonable and necessary" care for the work-related injury. The insurer will pay only for care related to the injury. If you are treating the patient for other conditions, keep a separate file and bill separately. You are generally the judge of what is reasonable and necessary. Most providers prefer to check with the claims representative and receive authorization before diagnostic procedures or interventions.

Return to work
You are responsible for notifying the patient when he is medically ready to return to work, and for explaining any temporary or long-term work restrictions. Make sure your Return to Work instructions are in writing and clear, so that they can be understood by your patient and by a manager or supervisor. The sooner you can release the patient to work, the better it will be for everyone. If the patient can return to work immediately, even on a light duty or restricted basis, that is preferable to staying home.
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Published by the New Mexico Workers' Compensation Administration, a state agency. Laws can change. Check for new information by calling 1-866-WORKOMP or 1-866-967-5667 or look on the Internet at www.workerscomp.state.nm.us

The Workers' Compensation Handbook for New Mexico Booklet B8: Quick Facts for Health Care Providers ______________________________________

2008 Edition page 4

For information on return to work issues, see: · The WCA's Guide for Health Care Providers (available on line or in print); · Booklet B3 of this series (available on line or in print); · the booklet "Stay at Work/Return to Work Program Guidebook."

Communicating with the employer
If the patient willingly gives you permission, you can converse with the employer or insurer. It is recommended that you obtain permission in writing through a release form that sets out the topics the patient has consented are open to discussion. (The patient is required by law to sign only the WCA release form, which is limited to written medical reports.) If the patient is represented by a lawyer, make sure the lawyer is kept informed.

Detailed information is available
The Guide for Health Care Providers, published by the WCA, is a book with detailed information. The Guide contains direct citations of the statute and Rules of the WCA by paragraph number. Part 4 of the WCA Rules ( 11.4.4.11 NMAC 2 ) covers emergency medical care; health care provider choice; hearing procedures related to health care provider choice; responsibility for payment of health care provider services. Part 7 of the WCA Rules (11.4.7 NMAC) covers maximum allowable fees and reimbursements for health care services and related non-clinical services; billing dispute procedures; pharmaceuticals dispensed by provider or pharmacy; and procedures for medical cost containment. The WCA medical fee schedule (titled the Physicians' Fee Schedule) is the detailed guide to the payments allowed by procedure code. Beginning in 2008, the current schedule is posted on the WCA web site at www.workerscomp.state.nm.us. Previous schedules were available in print only. Other publications for employers and workers are also published by the WCA. Some of the publications are downloadable from the WCA web site at www.workerscomp.state.nm.us. The WCA web site contains a "Proof of Coverage" searchable data base. Contact information for the employer's workers' compensation insurance carrier can be retrieved from that data base if the worker has the correct business name for the employer.

Published by the New Mexico Workers' Compensation Administration, a state agency. Laws can change. Check for new information by calling 1-866-WORKOMP or 1-866-967-5667 or look on the Internet at www.workerscomp.state.nm.us

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The Workers' Compensation Handbook for New Mexico Booklet B8: Quick Facts for Health Care Providers ______________________________________

2008 Edition page 5

Billing and payment
· · Always bill the payer, never the patient. If you are the first treating provider, your first bill should document your medical opinion that the patient's condition is due to a work-related injury (assuming that is genuinely your opinion). Send copies of medical notes with your bill. The adjuster has a responsibility to review medical services, to be sure they are reasonable and necessary. Use standard CMS forms with CPT codes and descriptors. The bill must have "WORKERS' COMPENSATION" or "WORK COMP" clearly printed or stamped at the top. Bill outpatient services within 30 days of the service. If you are asked for any special reports in addition to medical notes, or for additional copies of medical records, or certain other non-clinical services, you can bill for this additional service, under the Rules. Get a copy of the WCA's "Health Care Provider Guide" for more detailed information on billing and payment issues. Call any office of the WCA or download the book from the WCA web site at www.workerscomp.state.nm.us.

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· ·

· ·

·

Amount of payment
You may bill your usual and customary charges. The payer is required to limit payment to the Physicians' Fee Schedule, which is published by the WCA and updated annually. Some payers offer contracts to providers. Typically, the payer offers to give the provider a preferred status and in return the provider agrees to accept a lower payment. You are free to enter into contracts or not. If you do not, you don't have to accept any lower payment.

Balance billing is prohibited
You may not balance-bill the patient for any amount not paid by the insurer. However, if the claim is determined not to be covered by New Mexico workers' compensation, you may bill the patient or the patient's health insurance.
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Published by the New Mexico Workers' Compensation Administration, a state agency. Laws can change. Check for new information by calling 1-866-WORKOMP or 1-866-967-5667 or look on the Internet at www.workerscomp.state.nm.us

The Workers' Compensation Handbook for New Mexico Booklet B8: Quick Facts for Health Care Providers ______________________________________

2008 Edition page 6

Billing and payment disputes
The Workers' Compensation Administration has procedures to assist you. Get the Rules of the WCA, Part 7 (available online or in print) or contact the Medical Cost Containment Bureau of the WCA.

Pharmacy benefits
To the physician:
Whenever possible, prescribe a generic rather than a brand name. Check with the claims representative to find out if there is a preferred provider of pharmaceuticals that the patient can access conveniently and other limits on pharmaceuticals dispensed by the physician or pharmacy. Find this information at Rule 11.4.7.9 NMAC, Procedures for Establishing the Maximum Amount of Reimbursement Due, Section H.

To the pharmacist:
Payment for pharmaceuticals is governed by a formula in the medical rules. Find this information at Rule 11.4.7.9 NMAC, Procedures for Establishing the Maximum Amount of Reimbursement Due, Section H. Bill the payer, not the patient.

Dental care
As of year 2007, dental services are not listed in the Schedule of Maximum Allowable Payments. Payment can be made on a "by report" basis, which means that it is negotiated between payer and provider. Fees for any "by report" service should be negotiated prior to the performance of the service except in emergencies. (See the Rules of the WCA, paragraph 11.4.7.9(F)10 NMAC.)

Published by the New Mexico Workers' Compensation Administration, a state agency. Laws can change. Check for new information by calling 1-866-WORKOMP or 1-866-967-5667 or look on the Internet at www.workerscomp.state.nm.us

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The Workers' Compensation Handbook for New Mexico Booklet B8: Quick Facts for Health Care Providers ______________________________________

2008 Edition page 7

Help from the Workers' Compensation Administration
(See the list of offices and telephone numbers on the back page of this booklet) WCA publications If you are treating patients under the workers' compensation system, YOU SHOULD HAVE: · The Health Care Provider Guide to New Mexico Workers' Compensation;
· WCA Rules Part 7 and the Physicians' Fee Schedule. The book includes optional forms that you can use to report the patient's progress to the insurer or self-insurance program, and WCA forms that you can use in case of billing or payment issues.

For your patients:

This booklet is one of many in the series The Workers' Compensation Handbook for New Mexico. Other booklets in this series will be helpful to the patient in understanding his rights and responsibilities, including those related to medical care. See especially Booklet B4 concerning health care provider selection. The Workbook for Injured Workers is a book written just for injured workers, which explains the workers' compensation process in an orderly way. The OPTIONAL FORMS at the back of the Workbook assist a patient to track his own claim, including a form to be filled out after each medical visit, where the patient can record your instructions and recommendations. You can get publications from any office of the WCA. Telephone to request publications by mail. For downloadable publications, see below.

Personal contact
The WCA ombudsmen can assist you or your patients with most matters related to the claim. Call the Helpline number 1-866-WORKOMP / 1-866-967-5667, or your nearest WCA office. Encourage your patients to use this service unless they have retained a lawyer for their claim. The Medical Cost Containment Bureau can assist you with matters related to billing and payment, utilization review, case management, pre-approval procedure and similar matters.

WCA web site

www.workerscomp.state.nm.us

Most publications mentioned above can be downloaded from the WCA web site. The Physicians' fee Schedule is downloadable beginning in 2008.

Published by the New Mexico Workers' Compensation Administration, a state agency. Laws can change. Check for new information by calling 1-866-WORKOMP or 1-866-967-5667 or look on the Internet at www.workerscomp.state.nm.us

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The Workers' Compensation Handbook for New Mexico Booklet B8: Quick Facts for Health Care Providers ______________________________________

2008 Edition page 8

This list shows new titles and numbering system that will be in effect when the 2007 revision is completed. Some booklets are eliminated and others are renumbered. There are some changes from the pre-2007 editions of the booklets.
To get the information you need: Contact any office of the Workers' Compensation Administration for printed copies OR All booklets can be downloaded from the Workers' Compensation Administration web site at www.workerscomp.state.nm.us

Workers' Compensation Handbook List of Booklets

Booklet Booklet Booklet Booklet Booklet Booklet

A1(E) A1(S) A2 A3 A4 A5

Workers' Compensation Quick Facts- English Compensación A Los Trabajadores Informes Básicos ( Spanish) Setting Up a Workers' Compensation Program The Workers' Compensation Coverage Guide for Employers and Insurance Agents Uninsured Employers' Fund Workers' Compensation Personnel Assessment Fee (WC-1)

Booklet B1 What to Do after an Accident Booklet B2 Benefits for Workers While They Cannot Work Booklet B3 Going Back to Work Booklet B4 Medical Care in Workers' Compensation (B5 and B6 will be discontinued) Booklet B7 Información del sistema compensativo para los empleados (Spanish) Booklet B8 Quick Facts for Health Care Providers Booklet C1 When you need help with a workers' compensation claim Booklet C2 What to Do In Response to "Bad Acts" (C3 through 5 will be discontinued) Booklet D1 Booklet D2 Annual Safety Inspections How to Develop a Safety Program (published by the Advisory Council on Workers' Compensation and Occupational Disease Disablement)

(On the web site, look under Employers)
E3 E4

Guide to Completing and Filing Paper Copy for Employers' First Report of Injury or Illness (Form E1.2) and Notice of Benefit Payment (Form E6.2) EDI Guide to Completing the Employers' First Report of Injury or Illness (Form E1.2) and Notice of Benefit Payment (Form E6.2) -- limited to certified electronic filers

Other publications

Health Care Provider Guide to New Mexico Workers' Compensation Guidebook for Employers in New Mexico (English and Spanish) Workbook for Injured Workers (English and Spanish) The Stay at Work/Return to Work Program Guide
Wcamjd 9/07

Published by the New Mexico Workers' Compensation Administration, a state agency. Laws can change. Check for new information by calling 1-866-WORKOMP or 1-866-967-5667 or look on the Internet at www.workerscomp.state.nm.us

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The Workers' Compensation Handbook for New Mexico Booklet B8: Quick Facts for Health Care Providers ______________________________________

2008 Edition page 9

NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION
STATE HEADQUARTERS Mailing Address: Workers' Compensation Administration PO Box 27198, Albuquerque NM 87125 Location: 2410 Centre Avenue SE (near Yale-Gibson intersection) In-state toll-free phone: 1-800-255-7965 Local phone 841-6000 REGIONAL OFFICES: Southeastern regional office at Lovington: 100 West Central, Lovington, NM 88260 Telephone: 575-396-3437 In-state toll-free phone: 1-800-934-2450 Southwestern regional office at Las Cruces: 1120 Commerce Drive, Suite B-1, Las Cruces, NM 88011 Telephone: 575-524-6246 In-state toll-free phone: 1-800-870-6826 Northwestern regional office at Farmington: 3535 East 30th Street, Farmington, NM 87401 Telephone: 505-599-9746 In-state toll-free phone: 1-800-568-7310 Northeastern regional office at Las Vegas : 2515-2 Ridge Runner Road, Las Vegas NM 87701 Moving in 2008 to: 32 New Mexico 65, Las Vegas NM 87701 Telephone: 505-454-9251 In-state toll-free phone: 1-800-281-7889 Roswell Office: Penn Plaza Bldg., 400N. Pennsylvania Ave., Ste. 425, Roswell NM 88201 Telephone: 575-623-3781 In-state toll-free phone: 1-866-311-8587 Santa Fe Office: 810 West San Mateo, Suite A-2, Santa Fe, NM 87505 Telephone: 505-476-7381 Internet web site address: http://www.workerscomp.state.nm.us/ HELP & HOTLINE: 1-866-WORKOMP / 1-866-967-5667

mjdwca 1/08

Published by the New Mexico Workers' Compensation Administration, a state agency. Laws can change. Check for new information by calling 1-866-WORKOMP or 1-866-967-5667 or look on the Internet at www.workerscomp.state.nm.us

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